The objective of this study is to determine if evidence based treatment (EBT) for posttraumatic stress disorder (PTSD) leads to reduced risk of cardiovascular and metabolic disease (CMD) through adoption of healthy behaviors. PTSD affects approximately 7.7 million of Americans each year and is the 4th most common psychiatric disorder in the United States. One reason persons with PTSD develop CMD is poor health behaviors such as smoking, excessive drinking and sedentary lifestyle. Many patients will suffer premature morbidity and mortality unless we identify the mechanisms that mitigate the link between PTSD, poor health behavior and CMD. This 4-year R01 uses a cost efficient approach to investigate these issues by leveraging real-world clinic data from 4 sites in the Veterans Administration in which EBT is delivered with high fidelity, paired with repeat assessment of PTSD symptoms and merged with comprehensive medical records. We are not aware of similar multi-site sources of real world EBT clinic data in the private sector. EBT treatment data will be abstracted and merged with national medical record files resulting in a unique data base of 5,940 patients who engaged in EBT with about 40% completing treatment and 5,940 controls without PTSD. These data will allow us to determine, in Aim 1, if patients with PTSD, compared to controls, are less likely to engage in healthy behavior. In Aim 2, we determine if PTSD symptom reduction is associated with improved health behavior such as medication adherence, weight management and preventive care. In Aim 3 we determine if health behaviors moderate the contribution of PTSD symptom reduction to the risk of diagnosed CMD. In aim 4 we determine if a diagnosis of PTSD remains a risk factor for CMD even in patients who have symptom remission and improved health behavior. Last, in Aim 5, we derive a parsimonious predictive model of PTSD and incident CMD. Using propensity scores and inverse probability of treatment weighting, results from Cox proportional hazard models will disentangle the patient level factors, e.g. orientation toward health, associated with seeking and completing treatment from symptom reduction. This allows determining the independent contribution of PTSD symptom reduction and health behaviors. We believe the findings from our study will have important implications for clinical practice, guideline modifications, and the allocation of healthcare resources for all people with PTSD. If health behavior improves via PTSD symptom reduction, then clinicians should be trained to encourage health promotion during EBT. If patients remain at risk for CMD despite improved mental health and improved health behaviors, then life-long intensive monitoring of patients with PTSD is warranted to detect early signs of CMD.